Respiratory Flashcards
What are the 5 most common risk factors for developing asthma?
Exposure to allergens Living in a city Maternal smoking Family history Personal or FH of atopy
A seretide inhaler contains which drugs, should be taken how frequently?
Fluticasone and Salmeterol
Taken twice a day but can be reduced to one if well controlled
What three questions should be asked at an asthma review?
1- Have you had any difficulty sleeping because of your asthma symptoms (including cough)?
2- Have you had your usual asthma symptoms during the day? (SOB, cough, wheeze, chest tightness)
3- Has your asthma interfered with normal life at all, any problems at work or home?
Name 3 clinical features that make a diagnosis of asthma less likely?
Productive cough No wheeze/ repeated normal auscultation Dizziness/ lightheadedness Normal PEFR/ spirometry Voice disturbance
What is the carrier rate of the CF mutation? How is it inherited?
1 in 25
Autosomal Recessive
CF is caused by a mutation in which gene? What chromosome is it on?
CFTR gene
Chromosome 7
Name three possible presenting features of CF in a neonate?
FTT
Meconium ileus
Rectal prolapse
Name 5 possible features of CF in a child or young adult?
Cough/ wheeze
Recurrent infections/ bronchiectasis/ resp failure
Pancreatic insufficiency (diabetes, steatorrhoea)
Intestinal obstructions
Male infertility
Arthritis/ vasculitis
How should cystic fibrosis be diagnosed?
Sweat test <60 confirms (98% sensitive)
Genetic testing should also be done
What is the definition of ARDS? What are three common causes?
When non-cardiogenic pulmonary oedema leads to resp failure
because of damage to the alveoli
- Commonly due to sepsis, shock, trauma, pneumonia, gastric aspiration
Name 3 bedside tests used in respiratory medicine, when could they be indicated?
Peak flow - Asthma
What is the split between definitions of CAP and HAP?
HAP occurs > 48 hours after hospital admission
If <48hrs then still CAP
What is the commonest cause of CAP? (2)
Step pneumoniae (commonest)
H.influenzae
What is the commonest cause HAP?
Staph aureus
Name 5 symptoms which should be asked about in a pneumonia history?
Dyspnoea Cough Purluent sputum Fevers/ rigors Malaise Anorexia Haemoptysis Pleuritic pain
Name 5 signs of pneumonia?
Tachypnoea
Tachycardia
Cyanosis
Pyrexia
Confusion (often the only sign in elderly)
Hypotension
Consolidation signs (reduced expansion, dull percussion, crackles)
Name 3 tests you would perform for a patient presenting with signs of pneumonia?
O2 sats, blood pressure, pulse/ resp rate, temperature
If 2ndry care:
- FBC, U+E, LFT, CRP
- CXR
What scoring system is used for grading the severity of pneumonia, what are it’s parameters?
C- Confusion U- Urea >7 R - Resp rate >30 B- BP <90 65 - Age >65
0/1 - Oral antibiotics at home
2 - Hospital therapy
>3 - Severe (15-40% mortality) = consider ITU
What is first line antibiotic for mild CAP (CURB 0-1)?
PO Amoxicillin 500mg-1g TDS
5 day course
What is first line for a moderate CAP (Curb 2)
PO Amoxicillin 500mg-1g TDS
+ Clarithromycin 500mg BD
7-day course
Name three groups that should receive the pneumococcal vaccine?
> 65
Immunocompromised
Diabetes (non-diet controlled)
Chronic heart, liver, renal or lung conditions
A patient with a CAP is being discharged, what follow up is required?
Review at 6 weeks
+/- CXR
Name 3 complications of pneumonia?
Resp failure Hypotension AF Pleural effusion Empyema Lung abscess Sepsis
What is the most common site for lung cancers?
95% are bronchial
What are the two broad types of lung cancer plus the subtypes?
Small cell (15%)
Non-small cell (85%)
- Squamous (42%)
- Adenocarcinoma (39%)
- Large cell (8%)
- Carcinoid (7%)
What characterises small cell lung cancers?
Rapidly growing
Spread early and almost always inoperable
Poor prognosis but respond well to chemo
Which lung cancers most commonly release PTH?
Squamous cell carcinoma
Name three additional symptoms which may be seen in a PTH secreting tumour?
Features of high calcium
- Moans (abdo pain, N+V)
- Bones (bone pain)
- Stones (kidney)
- Thrones (on toilet as polyuria and polydipsia)
- Psychic groans
In a respiratory history name 5 red flags for lung cancer? (2ww)
Haemoptysis New hoarse voice Over 40 with: - Persistent chest infection - Clubbing - Supraclavicular lymphadenopathy Over 40 and smoker with: - Cough, SOB or chest pain - Weight loss or appetite loss
Where does lung cancer commonly metastasise to?
Brain and bone
Name 3 complications of lung cancer?
Recurrent laryngeal palsy Horners (pancoast tumour) SVC obstruction Metastasis and complications due to this Phrenic nerve palsy
How are lung tumours staged?
TNM
Tumour (Tx, Tis, T1-T4)
Nodes (N0,1,2,3)
Mets (M0,M1)
What is an aspergilloma, how is it seen on CXR and how is it treated?
Round ball of fungus in a chest cavity
Seen as ball in cavity like a halo on CXR
Treat if symptomatic - itraconazole,
What patient are at risk of aspergillosis?
Immunocompromised (Diabetes, long term broad spectrum AB’s etc).
(Diagnose with biopsy, treat with antifungals)
How do you grade COPD?
FEV1/FVC FEV1
< 0.7 > 80% Stage 1 - Mild
< 0.7 50-79% Stage 2 - Moderate
< 0.7 30-49% Stage 3 - Severe
< 0.7 < 30% Stage 4 - Very severe
What are the 4 features of acute severe asthma?
PEFR 33-50% best or predicted
Inability to complete full sentences
RR >25/min
Pulse >110 bpm
What are the diagnostic criteria for COPD?
FEV1/FVC < 70%
Clinical features
No other diagnosis more likely
Name three features which could help you distinguish between asthma and COPD?
Asthma diurinal variation (peak flow diary) - not in COPD
Asthma dry cough, COPD productive
Age of first presentation
What blood test should be performed for a young patient presenting with suspect COPD, no smoking hx?
ATA1
What are the first two lines of management of COPD?
1) Smoking + lifestyle
2) SABA or SAMA (salbuamol/ ipratropium) PRN
You have discussed smoking cessation with a COPD patient, and they are using a salbutamol inhaler PRN which is not controlling symptoms, what is line three of management?
Based of FEV1:
- If >50% (moderate) then add LABA or LAMA (Salmeterol or tiotropium)
- If <50% (severe) then give LABA and steroid as combined (seretide or symbicort)
A patient is using a salbutamol inhaler PRN and daily symbicort for their COPD, what is the next line of management?
All 4 drugs is 4th line
SABA (salbutamol)
LABA (in symbicort)
Steroid (in symbicort)
+ LAMA (tiotropium)
When starting a patient on a LAMA what must be done about their SAMA?
Stop SAMA
(Can’t take LAMA and SAMA)
- Although is fine to talke LABA and SABA
What are the indications for long term oxygen therapy for a patient with COPD?
Clinically stable and non-smoker with:
- paO2 <7.3kPa on two occasions at least 3 weeks apart
- paO2 and features of cor pulmonale
What is cor pulmonale, how does it present?
RV enlargement and dysfunction caused by resp disease
- Peripheral odema, neck vein distension, hepatomegaly etc
How is cor pulmonale diagnosed? What could be done to treat it?
On echo
Tx: Add frusemide
What general measures should be done to support all COPD patients?
Stop smoking, encourage exercise, tackle obesity and poor nutrition
Annual influenza and pneumococcal vaccines
Rescue packs of pred and antibiotics if frequent exacerbations
How do you determine between pneumonia and COPD exacerbations?
If there is radiographic consolidation, then it is pneumonia. If there is no radiographic consolidation, then the diagnosis is either acute exacerbation of COPD or infective exacerbation of COPD.
Name three investigations performed in A+E for a suspect exacerbation of COPD?
Sputum cultures
FB, U+E
CXR
ABG
(lung function tests are useless in exacerbation)
A patient has a suspected non-infective exacerbation of their COPD, what are you first three lines of treatment in A+E?
1) Controlled o2 therapy (88-92%)
2) Nebulised salbutamol (5mg) or ipratropium (0.5mg)
3) IV hydrocortisone, oral pred (30mg for 7-14days)
- If infective add AB
- Repeat nebs
4) Add IV aminophyline
5) Consider NIV
What are the indications for NIV in an exacerbation of COPD?
RR >30
pH <7.35
What scoring system is used to predict the severity and prognosis of COPD?
BODE index
- BMI
- Obstruction
- Dyspnoea
- Exercise capacity
What are the three main pharmacological options for smoking cessation therapy?
NRT (use for 8 weeks)
Bupropion
Varenicline
Name 5 symptoms of cigarette withdrawl
Worsening cough Weight gain irritability/ anger Anxiety/ depression/ insomnia Tingling in peripheries Headaches and nausea
What two categories can pleural effusions be divided into?
Transudate (low protein, due to high pressure- failures)
Exudate (high protein, due to inflammation- cancer, infection)
Name three causes of a transudate effusion?
Heart failure
Liver failure
Kidney failure
Name two causes of an exudate pleural effusion?
Pneumonia
Malignancy
What is the main treatment for recurrent pleural effusions?
Continued tapping (often in paliative care)
Pleurodesis (seals visceral and parietal pleura - tetracycline/ talc/ bleomycin used)
Name 5 risk factors for developing asthma
Atopy Inner city/ low SES Obesity Low birth weight Smoking or maternal smoking
What are the 4 main symptoms of asthma?
SOB/ wheeze/ chest tightness/ cough
Asthma symptoms are worse with (4)
At night/ early morning With cold With exercise With allergen exposure With emotion After taking aspirin/ BB
How is the diagnosis of asthma made?
Clinically
although investigations like PEFR and spirometry can be helpful
What investigations could be performed for a patient with asthma?
PEFR diary (Diurinal variation of >20% suggests asthma)
Spirometry (when symptomatic) - obstructive pattern, >20% improvement with salbutamol is likely asthma
When should investigations be considered to support an asthma diagnosis in children?
High likelihood - trial salbuatmol
Intermediate likelihood - investigate before starting Tx
How do you define asthma?
Recurrent episodes of reversiable airway obstruction
When should investigations be considered to support an asthma diagnosis in adults?
First do clinical investigations (Ideally spirometry but if not peak flow)
High probability > Start tx
intermediate > Do spirometry, start if FEV1/FVC is <70%
What are the first 7 steps in management of stable asthma?
noting that you should start at the most appropriate step
1) SABA
- If night syx or using >1/day move on:
2) + ICS (200-800mcg)
3) Add LABA
4) Increase ICS up to 2000mcg/day
5) Consider montelukast/ theophylline
6) Consider low dose oral steroid
7) Refer for specialist care
When can you move down a step in the asthma ladder?
If control has been good for >3 months
Name five key side effects of salbutamol?
Tachycardia/ tachyarrythmia's Fine tremour Headache Hypokalaemia Anxiety
How does asthma management change in pregnancy?
It doesn’t!
Name three indications for starting an ICS along with a SABA?
- Exacerbations of asthma in the last two years
- Using inhaled β2 agonists three times a week or more
- Symptomatic three times a week or more
- Waking one night a week
Name three inhalers which combine a LABA and an ICS?
Seretide
Symbicort
Fostair
Name 5 features of life threatening (i.e. worse than severe) asthma?
PEFR <33% Silent chest Cyanosis Hypotension Bradycardia Exhaustion
Name 3 features of a blood gas in life threatening asthma?
High pCO2
O2 < 8kPa
Resp acidosis (low pH)
What are your first seven steps in the management of acute severe asthma?
1) ABCDE + Call ITU
2) 15L O2
3) Salbutamol nebs 5mg
- If severe add ipratropium 0.5mg
4) Hydrocortisone 100mg IV and/or prednisolone 40mg IV
5) Add magnesium sulphate 1.2mg IV over 20mins
6) Add aminophylline IV
7) Transfer to ITU
A patient has been admitted with an asthma attack and is now being discharged, what medication should he be sent home on?
Inhalers as before
Pred 40-50mg for 5-7 days
Consider stepping up maintenance treatment
During an acute asthma attack a patient is beginning to improve, what steps should be taken (3)?
Continue obs and peak flow eveyr 15mins
Continue nebs (15mins) til PEFR is 75% then step down to nebs every 4-6hours
Written plan, technique checked, oral steroid and outpa`tient resp follow up booked before discharge
A 22-year-old woman attends the Emergency Department following an exacerbation of asthma. She currently only uses a salbutamol inhaler 2 puffs prn. Her symptoms settle quickly with a salbutamol nebuliser. You give the patient standard advice on inhaler technique and what to do if her symptoms return. What is the most appropriate further action to ensure that this current exacerbation settles?
A: Prescribed oral prednisolone 40mg for 5 days (with STAT dose now)
- This is the most effective action to settle her exacerbation
- If symptoms persist she needs treatment escalating (beclametosone inhaler)
What is a normal PaCO2 on a blood gas?
4.5 - 6.0 kPa
What is a normal PaO2 on blood gas?
10-14kPa
always 10 less than inspired oxygen, atmosphere is 21%
What is normal bicarbonate on blood gas?
22-28
What is sarcoidosis and give 3 example features?
Sarcoidosis is a multisystem disorder of unknown aetiology characterised by non-caseating granulomas.
- Acute: Polyarthralgia, hilar lymphadenopathy, erythema nodosum
- Insidious: SOB, fatigue, weight loss, no productive cough
Who does sarcoidosis tend to most affect? What blood test is most useful?
Affects young africans
Has high serum ACE levels
A patient with COPD presents to A+E with an exacerbation, here blood gas is as below, what should her target O2 sats be?
pH 7.38
pCO2 4.9 kPa
pO2 8.8 kPa
94-98%
Prior to availability of blood gases, use a 28% Venturi mask at 4 l/min and aim for an oxygen saturation of 88-92% for patients with risk factors for hypercapnia but no prior history of respiratory acidosis
adjust target range to 94-98% if the pCO2 is normal
What organism is responsible for most infective exacerbations of COPD?
Haemophilus influenzae
Name 5 non drug causes of intersitial lung disease?
Idiopathic pulmonary fibrosis Asbestosis Silicosis Hypersensitivity pneumonitis (pigeon work) Radiation therapy SLE
Name 3 drug causes of lung fibrosis?
Methotrexate
Amiodarone
Bleomycin
Nitrofurantoin
Name 4 features of lung fibrosis?
Slow, progressive SOB
Dry cough
Bilateral, fine crackles
Finger clubbing
Name 3 treatments for lung fibrosis?
Regular exercise/ weight loss
O2 therapy for those with resting hypoxia
Omeprazole (proven survival benefit)
Prednisolone/ pirfenidone (specialist centres)
Transplant
Name 4 symptoms of bronchitis?
Hacking cough Sputum (clear, yellow, green) Sore throat Headache Running nose Aches and pains
What is Kartagener’s syndrome? Name the 4 main features.
Primary ciliary dyskinesia
- Dextrocardia or sinus invertus
- Bronchiectasis/ frequent infections
- Recurrent sinusitis
- Subfertility
Name 5 risk factors for DVT?
Hx/Fhx (strongest) Immobilisation COCP/ HRT Pregnancy Active cancer Smoking Obesity
Name 5 components of a Well’s score for DVT?
Active cancer Bedridden >3days or maj surgery in 4 weeks Calf swelling >3cm compared Localised tenderness Pitting oedema on one leg Previous DVT Alternative as likely (-2)
How do you investigate a suspected PE if:
a) Wells score 0-1
b) Wells score >2
a) Do D-dimer
- If -ve rule out
- If +ve do doppler
b) Do USS
- If -ve do D-dimer
- If +ve treat
Remember if no predisposing factors do coagulation screen also
How is a DVT treated?
LMWH (5 days minimum)
If starting warfarin wait until INR >2 for at least 24hrs
(whichever of the above is longest)
How long before an operation should the COCP be stopped?
4 weeks
For how long should a patient with a DVT or PE be given anticoagulation for with warfarin or a DOAC?
Min 3 months
- If unprovoked consider 6 months
- If clot when on anticoag then give lifelong
What is post-thrombotic syndrome, name 5 symptoms?
Venous hypertension post DVT (affects 20-40%)
- Pain, swelling
- Hyperpigmentation/ dermatitis
- Ulcers, gangrene
- Lipodermatosclerosis
What travel advice is given to patients if asking about DVT prevention?
Low risk (precautions like stretching) Mod risk (give compression stocking) High risk (give LMWH)
What are the components of a two level wells score for PE?
Signs of DVT = 3 HR >100 = 1.5 Recent immobilised = 1.5 Previous DVT/PE = 1.5 Haemoptysis = 1 Cancer in last 6/12 = 1 Alternative diag less likely = 3
How do you investigate a PE after calculating wells score?
Score >4: - Immediate CTPA - If delay treat with LMWH Score <4 - Do D-dimer (If +ve do CTPA) (If -ve consider alternative)
How should a suspected PE (wells of 6) be treated in a patient with hypotension?
Thrombolyse
How should a stable patient with a proven PE on CTPA be treated?
LMWH for 5 days
Warfarin or DOAC for min 3 months
Continue LMWH until INR >2 for >48hrs or 5 days, whichever is longer
How should a patient with an unprovoked PE be managed in addition to anticoagulation?
Check for cause
Clotting screen, cancer screen
Name 3 risk factors for pneumothorax?
Smoking (biggest) Trauma Recent invasive chest procedure Secondary (COPD, asthma, pneumonia, CF) FHx
What are the presenting features of a pneumothorax?
Dyspnoea and pleutric chest pain (2/3 of all)
Tachycardia, tachypnoea, sweating
How is a primary pneumothorax treated?
If asymptomatic and <2cm ring of air = Discharge, r/w in 4 weeks
If >2cm air or SOB = Aspiration
- Successful = Discharge and r/w in 4 weeks
- Unsuccessful = Chest drain
How is a secondary pneumothorax treated?
If SOB and >2cm = chest drain
If SOB and 1-2cm = Aspirate
If asymptomatic and <1cm = admit and observe with O2
What is in a COPD rescue pack?
Doxycycline
Prednisolone
What is the most common causes of SVC obstruction?
Mediastinal pressure due to lung cancer (85%)
Lymphoma is next most common
Name 5 presenting symptoms of SVC obstruction?
Dyspnoea Cough Chest pain Neck/ face/ arm swelling Dizziness Syncope
Symptoms worse bending over or lying down
Name 3 signs of SVC obstruction?
Dilated veins over arms, neck and chest wall
Oedema of upper body extremities and face
Resp distress
Cyanosis
How is SVC obstruction usually managed?
Address underlying cause
- Stenting (1st line) or radiotherapy are options
Dextamethosone can be helpful in acute setting
What form of lung cancer is most common in non-smokers?
Adenocarcinoma
When there is consolidation on the lungs what will happen to vocal resonance?
Increased (because of denser tissue)
> Would be decreases if more air or fluid
What are some of the key features of an empyema?
Fever following pneumonia which doesn’t respond to antibiotics
Aspiration of pleural fluid with pH <7.2
What are the features of a mycoplasma pneumonia?
Atypical presentation
Younger patient
Erythema multiforme (ring shaped rash)
Haemolysis (anaemia)
